Margaret Megan Evans · Prevention of Future Deaths report

On the 6th of February 2018 I commenced an investigation into the death of Margaret Megan Evans (DOB 28.12.24 DOD 5.2.18) The investigation concluded at the end of the inquest on the 22nd of June 2018. The conclusion of the inquest was one of an accidental death the Cause of Death being recorded as 1(a) Hospital Acquired Pneumonia 2. Fractured Neck of Femur

On the 22nd of January 2018 the Deceased fell outside her home and sustained a fractured hip as a result. An ambulance was summoned to assist her at 10.32 however no ambulances were available and an ambulance did not arrive until 13.51. Thereafter she left the scene at 14.25 arriving at the Emergency Department of the Maelor Hospital, Wrexham at 14.51.

Due to the department being busy she was not brought in until 21.22 and was seen by the consultant at 21.28.

As a consequence of the above the Deceased had to endure more than three hours lying on a concrete path and was not seen by the ED doctor until almost eleven hours after help was initially summoned although it cannot be said that these delays contributed to her death.

The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.

Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result.